Putting the ‘Care’ in Health Care

Posted on Apr 2, 2009

By Ellen Goodman

I was tickled to hear that the insurance industry is beginning to commence to start to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system.

But there is a pre-existing condition that hasn’t garnered nearly as much attention in the health care debate. It’s the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry.

Health care reform has focused, rightly enough, on the 50 million uninsured Americans. Reformers are homing in on price tags that are off the (medical) charts. We are told of financial fixes and electronic records that will save the day, or at least the budget.

But speaking as the CEO of a wholly owned body, I don’t think we’re talking enough about the care in health care.

Consider one of the least secret medical records in the country: the erosion of primary care doctors. A half-century ago, we had an equal number of generalists and specialists. Today there are two specialists for every generalist.

In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, “It’s absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment.” The incentives tip toward the kind of medicine that is performed with hands, tools and technology over the medicine that is practiced with eyes, ears and mind.

The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls “proceduralists.” They enter with a strong desire to look after families and exit with a ticket to X-ray femurs.

It was this business model that produced both runaway costs and discontent. Now we are told that a business model can fix it. But this is by no means certain.

As Drs. Jerome Groopman and Pamela Hartzband wrote in a thoughtful New England Journal of Medicine piece on the changing culture of their profession, medicine is about more than metrics. It is both a “market relationship” in which you provide goods for services, and a “communal relationship,” built on a family model, in which doctors are expected to help when help is needed, regardless of money.

“Assigning a monetary value to every aspect of a physician’s time and effort,” they write, “may actually reduce productivity, impair the quality of performance and thereby even increase costs.” All while undermining the communal relationship. More to the point, the business models don’t touch the basic problem of an out-of-kilter system favoring CT scans over human connections.

“The really hard conversation is not going on,” says Groopman about health care reform. “The hard conversation involves what we value as a society and what translates into the kind of care we all want.” The “kind of care we all want” includes a known doctor who can diagnose, manage, coordinate and comfort.

This is especially important in an aging society. “I can’t see an 88-year-old man for 15 minutes and find out what’s wrong,” says Groopman. He compares the difference between high-tech and “cognitive medicine” to the difference between “CSI” and Sherlock Holmes. Spending time with a patient “isn’t about having a beer together. It’s about getting a story and figuring out the treatment that makes sense.”

There is nothing entirely new in the discontent of doctors and patients, the shredding of personal relationships, or the shrinking pool of primary care doctors. It’s been chronicled in conversations and commissions dating back as far as Richard Nixon. Yet it has continued unabated.

President Obama passed a glancing eye at the problem during his recent news conference when he said, “Let’s reimburse on the basis of improved quality, as opposed to simply how many procedures you’re doing.” Rebuilding the culture of medicine and recruiting a new cohort of primary care doctors are, in themselves, part of that improved quality.

Speaking for my pre-existing condition of being human, it’s the family doctors, the primary caregivers, who put the care in health care. Yet we talk of finance and efficiency, and the designated superhero is the electronic record keeper. Are we to pin our hopes on that? Take two aspirin and call your computer in the morning.